Analysis of Nutritional Supplements Use in Turkish Elite Skiers

Analysis of Nutritional Supplements Use in Turkish Elite Skiers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of Nutritional Supplements Use in Turkish Elite Skiers Elif Günalan, Antonio Jesús Sanchez-Oliver, Saadet Turhan, Öykü Altınok, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6251321/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Winter sports athletes are challenged with increased energy expenditure, glycogen utilization, and fluid loss due to cold environmental conditions. Nutritional supplements (NS) may provide improved health or performance, more effective training, and a direct performance advantage for winter sports athletes like skiers. Aims This study evaluates NS consumption in Turkish elite skiers of different competition fields (Alpine skiing vs. Cross-country skiing) and levels (national vs. international) according to Australian Sports Institute (AIS) criteria. Methods Thirty-nine Turkish elite skiers (Alpine, n = 27 and Cross-country, n = 12) completed an NS consumption-related specific questionnaire, which included parts of personal characteristics, sports/ training, and consumption patterns of NS. Results Although 74.4% had previously used NS, only 28.2% consumed them during the study season. No significant differences were found in NS use between skiing disciplines (p = 0.709) or competition levels (p = 0.342). The most common reasons for NS use were health maintenance (28.2%) and performance enhancement (25.6%). Popular NS included vitamin C (23.1%), vitamin D (15.4%), and green tea (10.3%), with pharmacies (28.2%) and the Internet (15.4%) being the main purchasing sources. Physicians (23.1%) and dietitians (15.4%) were the primary advisors, although no significant differences were observed between groups regarding supplement use. Conclusion This study highlights that NS consumption among Turkish elite skiers is lower than in other endurance sports and is not significantly influenced by competition type or level. The findings emphasize the need for enhanced education on evidence-based supplementation strategies tailored to the unique demands of winter sports. Athletes Dietary Supplements Winter Sports Sport Supplements INTRODUCTION Skiing, an intermittent strength-endurance activity, is performed at medium to high intensity [ 1 ]. It takes place on ice or snow, in cold conditions (air temperature between − 25 and + 5°C), and at medium to high altitudes (average 2500 m) [ 2 , 3 ]. Skiers have unique nutritional needs due to the nature of their sport. For instance, they require increased energy intake to fuel their rigorous activity, and they need to replenish their glycogen stores due to the intense muscle contractions that occur throughout a turn. These repeated stimuli force the glycolytic energy system and thus affect muscle glycogen stores [ 4 ]. Despite their rigorous training, winter sports athletes face myriad unique nutritional challenges due to the demanding conditions of their sport. These challenges, including increased energy expenditure, accelerated glycogen utilization, fluid loss, and iron conversion, significantly impact their nutritional status and can lead to metabolic, thermoregulatory, and cardiovascular complications [ 3 ]. Cold exposure increases the glycolytic capacity and glycogenolysis [ 5 ]. Significant levels of ischemia and hypoxia may occur while skiing [ 6 ]. Ischemia may negatively affect metabolism by increasing glycogen utilization or decreasing glucose uptake by muscle [ 7 ]. Altitude also increases the iron requirements due to its role in oxygen transport and energy metabolism [ 8 ]. Fluid balance is a cornerstone of exercise performance and athlete health in winter sports [ 9 ]. Exposure to altitude triggers diuresis, decreases thirst, and improves ventilation in low-humidity environments, posing a risk of dehydration and decreased total body water [ 3 , 9 ]. These factors, when combined, can lead to rapid onset of fatigue, impaired performance, and various nutritional complications at low temperatures and high altitudes [ 3 ]. Energy, nutrient, and fluid intake are critical to skiers [ 10 ]. Nutritional deficits can adversely impact the performance and health of athletes [ 2 ]. Several previous studies have unfortunately pointed out that skiers' dietary habits are insufficient to meet the needs of the sport [ 11 ]. Studies have demonstrated deficiencies in athletes' fluid intake [ 9 ], energy intake [ 2 , 11 , 12 ], carbohydrate consumption [ 12 ], and vitamin and mineral intake [ 2 , 11 ]. Exposure to high altitudes may exacerbate these deficiencies [ 2 ]. For skiers, specific supplements can be particularly beneficial. For instance, carbohydrate supplements can help replenish glycogen stores, and iron supplements can address the increased iron requirements due to altitude exposure. Nutritional supplements (NS) are "food, food component, nutrient, or non-food compound that is purposefully ingested in addition to the habitually consumed diet to achieve a specific health and performance benefit". NS aim to supplement dietary deficiencies by containing substances with nutritional or specific physiological effects [ 13 – 14 ]. They may be in capsules, tablets, pills, granules, chewable tablets, or gums [ 15 ]. Supplements are essential in improving sports performance and supporting exercise programs [ 16 ]. However, the key to their effectiveness lies in using appropriate supplements at the right time. This can increase athletes' sports performance, accelerate recovery, and delay fatigue [ 17 ]. The use of NS by athletes and people participating in sports activities has increased significantly over the past few decades [ 18 ]. It varies between 30% and 95% depending on the sport, gender, age, or level of competition [ 19 – 21 ]. In addition, the supplement market is constantly expanding, and the variety of products continues to increase [ 18 ]. Only a tiny portion of the supplements available on the market have demonstrated significant effects on performance despite their widespread use and growing market [ 14 ]. Therefore, selecting the appropriate and safe product based on the specific characteristics of the sport and the athlete's condition has become a crucial issue [ 3 , 22 ]. Some studies have reported potential beneficial effects of NS consumption on muscle damage, perceptions of effort, training volume, and sports performance in skiers of certain ages and genders across different skiing disciplines [ 23 – 25 ]. These findings offer promising potential for NS to enhance skiers' performance significantly. However, limited studies have examined the prevalence of supplement use in skiers [ 26 ]. Therefore, this study aims to investigate NS consumption profile in Turkish elite skiers of different competition fields and levels. MATERIALS AND METHODS Study design This cross-sectional study examined the NS consumption patterns of Turkish skiers in the Alpine and Cross-country disciplines. Participants This study aimed to reach all elite Alpine or Cross-country skiing volunteer athletes affiliated with the Türkiye Ski Federation. For this purpose, approval was obtained from the Yeditepe University Non-Interventional Clinical Research Ethics Committee (Meeting Date: 13.01.2023; Application Number: 202301Y0338). Afterward, legal permissions were obtained from the federation for cooperation. The federation shared the contact numbers of the authorities in all provinces and contributed to reaching the athletes. After telephone interviews with provincial ski authorities, data collection form links were sent to the skiers’ coaches. Participants completed an online NS consumption-related specific questionnaire in Google Forms (Google, Mountain View, CA, USA). The calculation for the sample size was performed using the Sample Size Calculator from the Australian Bureau of Statistics with a confidence level set at 95% ( https://www.abs.gov.au/websitedbs/D3310114.nsf/home/Sample+Size+Calculator ). Based on information from the Turkish Ski Federation website, the target population comprised 8,900 skiers at both national and international levels ( https://tkf.org.tr/ ). Assuming an anticipated proportion of 0.9, the resulting sample consisted of 36 skiers, featuring a confidence interval of 0.09, a standard error of 0.05, and a relative standard error of 5.56. Inclusion criteria included being an elite skier, 18 or older, and competing in Alpine or Cross-country skiing branches. At the end of this process, 39 elite skiers (13 female, 26 male) in the Alpine and Cross-country disciplines participated in the study. Data collection form A previously validated questionnaire was used for data collection, having undergone thorough content, structure, and applicability reviews [ 27 ]. This questionnaire, assessed for methodological quality in a systematic review and meta-analysis by Knapik et al. (2016), was identified as one of 57 validated instruments out of 164 assessed, demonstrating its suitability for obtaining precise data on sports supplement (SS) use among athletes. The validation process by Knapik et al. (2016) utilized an eight-point scale, evaluating factors such as sampling, sample size, measurement tools, bias, response rate, statistical presentation, and participant sample description [ 19 ]. The questionnaire consisted of three main sections: (a) anthropometric and personal data (age, weight, height, years of federation, weekly training days and hours, number of competitions per year); (b) sports practice, including competition category, experience level, weekly training hours, and number of training sessions; and (c) SS consumption habits. This final section explored various aspects of SS use, including types of supplements used, reasons for consumption (e.g., performance enhancement, health maintenance, aesthetics), sources of information (e.g., dietitian/nutritionist, friends, family, physical trainer, physicians), purchasing locations (e.g., pharmacy, internet, specialized stores), frequency and timing of consumption (before, during, and after training/competition), and perceived effects on health and/or athletic performance. Additionally, questions regarding the use of prohibited substances were included, along with a definition of SSs and an updated supplement list [ 27 ]. The questionnaire has been successfully employed in numerous prior studies to assess athletes' patterns of SS use [ 20 , 28 – 29 ]. Further details regarding the instrument and its user manual can be found in the user guide developed by Sanchez-Oliver et al. (2024) [ 30 ]. NS consumption were rigorously categorized using the AIS classification system, a robust framework backed by substantial scientific evidence. In this system, Group A supplements have the most substantial scientific evidence and include three subgroups: sports foods (sports drinks, sports gels, sports confectionary, electrolyte supplements, isolated protein supplements, and mixed macronutrient supplements), medical supplements (iron, calcium, vitamin D, multivitamin complexes, probiotics, and zinc), and performance supplements (caffeine, β-alanine, dietary nitrate/beetroot juice, sodium bicarbonate, creatine monohydrate, and glycerol). Group B supplements with newly emerging scientific evidence are fruit-derived polyphenols, vitamin C, N-acetyl cysteine, menthol, quinine, transient receptor potential channel agents, collagen, curcumin, ketone, fish oils, and carnitine. Group C supplements have not been scientifically proven to provide any advantage to the athletes, and these are magnesium, branched-chain amino acids (BCAA)/leucine, vitamin E, alpha lipoic acid, phosphate, tyrosine, hydroxymethyl butyrate, and prebiotics. Supplements may shift to different groups based on alterations in scientific evidence [ 31 ]. Statistical analysis The statistical analyses of the data were analyzed using Jamovi for MacOS , version 2.5.4 . In this study, the dependent variables were the parameters related to the athletes' NS consumption, while the independent variables included the type of competition fields and levels. The distribution's normality was examined by applying the Shapiro-Wilk test. For those quantitative variables that met the criteria for normal distribution, an independent sample t-test was used. For all other pairwise comparisons, the Mann-Whitney U Test was performed. Furthermore, the chi-square and Fisher's exact tests were utilized to assess the qualitative parameters, and the odds ratio (OR) was determined to estimate the difference based on competition fields ( Alpine vs. Cross-country ) and levels ( national vs. international ). RESULTS Thirty-nine elite skiers participated in the study, with 27 Alpine skiers (69.2%) (9 female, 18 male) and 12 cross-country skiers (4 female, 8 male) (30.8%). Among these athletes, 56.4% compete at the national level, while 43.6% compete at the international level. The average age of participants was 23.0 ± 8.78. The education levels of skiers were BSc degree (43.6%), MSc (12.8%), and high school or below degree (43.6%). The average number of weekly training sessions was 5.3 ± 3.7. The average session duration mainly was 31–60 minutes (28.2%), 61–90 minutes (28.2%), and 91–120 minutes (15.4%). According to the competition level and type of the skiers, there were no significant differences in age and weekly training sessions in skiers (p > 0.05). Although 74.4% of participants previously had used at least one NS, only 28.2% of all participants use them in the season that is carry on the study. Additionally, 56.4% of participants reported being familiar with NS usage laws. The average number of NS consumptions’ of skiers was 1.2 ± 1.4. Analysis of current NS usage showed no significant difference in sports discipline ( p = 0.709 ) (Alpine 25.9% vs. Cross-country 33.3%; OR = 0.70 [0.16–3.07]) or competition level ( p = 0.342 ) (national 22.7% vs. international 35.3%; OR = 0.54 [0.13–2.21]). Participants mainly preferred NS on the training day (20.5%) before (12.8%) or after (12.8%) sports practice. Regarding the purpose of NS consumption, to take care of health (28.2%) and to improve sport performance (25.6%) were the most popular, with no statistical significance based on the competition field and levels ( p > 0.05 ). Nevertheless, international and cross-country skiers more often consumed NS to increase sports performance, while international and alpine skiers frequently consumed NS to care for their health. The most common places for skiers to purchase NS were Pharmacies (28.2%) and the Internet (15.4%). Cross-country and national competitive skiers preferred NS from the Internet more, while alpine and international skiers mainly purchased NS from pharmacies. However, there were no statistically significant differences in this issue. The main advisors of the participants in NS consumption were physicians (23.1%) and dietitians (15.4%), but the distribution between the groups is quite close to each other in this regard, and there were no statistically significant differences (Table 1 ). Table 1 Differences in parameters related to NS consumption according to sports field and levels. Parameters Alpine (n = 27) % Cross-Country (n = 12) % p-value OR National (n = 22) % International (n = 17) % p-value OR Purpose of Use -to improve sport performance 18.5 41.7 0.232 3.14 [0.70–14.1] 18.2 35.3 0.282 a 2.45 [0.56–10.7] - to take care of health 33.3 16.7 0.446 a 0.40 [0.07–2.23] 22.7 35.3 0.387 1.85 [0.45–7.58] The Place of NS Purchase -In internet 7.4 33.3 0.06 a 6.25 [0.96–40.7] 18.2 11.8 0.679 a 0.60 [0.09–3.74] -In a pharmacy 33.3 16.7 0.446 a 0.40 [0.07–2.23] 18.2 41.2 0.158 a 3.15 [0.74–13.4] NS Consumption Advisors -Physician 22.2 25 1.00 a 1.17 [0.24–5.73] 18.2 29.4 0.465 a 1.87 [0.42–8.44] -Dietitian 14.8 16.7 1.00 a 1.15 [0.18–7.33] 18.2 11.8 0.679 a 0.60 [0.09–3.74] a indicates Fisher exact test. According to the AIS classification of NS (Group A – subgroups Sport Foods, Medical Supplements, and Performance Supplements –; Group B and Group C), there were no statistically significant differences in types (Table 2 ) and competition levels (Table 3 ). Table 2 Differences in type of supplement consumption according to the type of competition. AIS Classification Alpine (n = 27) Mean ± SD Cross-country (n = 12) Mean ± SD Overall (n = 39) Mean ± SD p-value a Group A Sports Foods 0.11 ± 0.32 0.17 ± 0.39 0.12 ± 0.34 0.655 Medical Supplements 0.33 ± 0.62 0.25 ± 0.45 0.31 ± 0.57 0.873 Performance Supplements 0.07 ± 0.27 0.17 ± 0.39 0.10 ± 0.31 0.401 Total Group A 0.52 ± 0.75 0.58 ± 0.52 0.54 ± 0.68 0.468 Group B 0.26 ± 0.45 0.25 ± 0.45 0.26 ± 0.44 0.968 Group C 0.41 ± 0.69 0.42 ± 0.67 0.41 ± 0.68 0.956 a p values were calculated via the Mann-Whitney U test. a p values were calculated via the Mann-Whitney U test. The most popular NS for Turkish skiers were vitamin C (23.1%), vitamin D (15.4%), green tea (10.3%), caffeine (7.7%), omega-3 (7.7%), whey protein (7.7%), zinc (7.7%), multivitamin complex (5.1%), pollen (5.1%), magnesium (5.1%), and royal jelly (5.1%). Since the supplement usage rates of subjects are low, further analyses were performed for the most preferred supplements. The analysis of NS consumption among elite skiers reveals no statistically significant differences between alpine and cross-country disciplines or between national and international competitors for most supplements. For instance, vitamin C (Group B) was used by 25.9% of Alpine and 16.7% of Cross-Country skiers (p = 0.693; OR = 0.57 [0.10–3.27]), with similar usage between national (22.7%) and international (23.5%) competitors (p = 1.00; OR = 1.05 [0.23–4.69]). Similarly, vitamin D (Group A) consumption was comparable across groups (14.8% vs. 16.7%; p = 1.00), as was the use of green tea (Group C) and omega-3 (Group B). Caffeine (Group A) usage showed a trend towards higher consumption among cross-country skiers (16.7% vs. 3.7% in alpine; p = 0.219; OR = 5.20 [0.42–63.9]), although this did not reach statistical significance. Notably, supplements such as whey protein and zinc (both Group A) were reported by 11.1% of alpine skiers but by none of the cross-country skiers, yet the differences were not significant (p = 0.539). An exception was magnesium (Group C), where 0% of alpine and 16.7% of cross-country skiers reported usage, showing a borderline significance (p = 0.089; OR = 13.1 [0.58–296]), suggesting a possible higher reliance on magnesium among Cross-Country athletes (Table 4 ). Table 4 Differences in the top ten supplement consumption among skiers by competition fields and levels. Type of Supplement Alpine (n = 27) % Cross-Country (n = 12) % p-value a OR National (n = 22) % International (n = 17) % p-value a OR Vitamin C 25.9 16.7 0.693 0.57 [0.10–3.27] 22.7 23.5 1.00 1.05 [0.23–4.69] Vitamin D 14.8 16.7 1.00 1.15 [0.18–7.33] 14.8 16.7 1.00 1.36 [0.24–7.75] Green Tea 11.1 8.3 1.00 0.72 [0.07–7.80] 13.6 5.9 0.618 0.40 [0.04–4.19] Caffeine 3.7 16.7 0.219 5.20 [0.42–63.9] 4.5 11.8 0.570 2.80 [0.23–33.8] Omega-3 7.4 8.3 1.000 1.14 [0.09–13.9] 9.1 5.9 1.000 0.63 [0.05–7.53] Whey Protein 11.1 0.0 0.539 0.28 [0.01–5.86] 4.5 11.8 0.570 2.80 [0.23–33.8] Zinc 11.1 0.0 0.539 0.28 [0.01–5.86] 9.1 5.9 1.000 0.63 [0.05–7.53] Pollen 3.7 8.3 0.526 2.36 [0.14–41.3] 4.5 5.9 1.000 1.31 [0.08–22.6] Magnesium 0 16.7 0.089 13.1 [0.58–296] 4.5 5.9 1.000 1.31 [0.08–22.6] Multivitamin Complex 3.7 8.3 0.526 2.36 [0.13–41.3] 4.5 5.9 1.000 1.31 [0.08–22.6] a indicates Fisher exact test. DISCUSSION The present study provides novel insights into the consumption patterns of nutritional supplements (NS) among elite Turkish skiers, specifically in the alpine and cross-country disciplines. The findings reveal that while the majority of participants (74.4%) reported previous NS use, only 28.2% were currently using them during the study period. This prevalence is lower than that observed in endurance athletes such as triathletes and mountain runners, where NS consumption often exceeds 90% [ 32 – 33 ]. Moreover, there weren´t differences by level or field, in contrast to a study of international alpine and cross-skiers in Norway, where Ronsen et al. (1999) found that 95% of cross-country skiers used more supplements than 70% of alpine skiers [ 26 ]. These findings differ significantly from other studies with elite athletes, as we observed a very low consumption of NS and no difference in consumption prevalence between national and international athletes [ 19 – 34 ]. These differences may be attributed to the intermittent nature of skiing and the potential underestimation of nutritional needs in this sport. A key finding is that no significant differences were observed in NS consumption based on competition type (alpine vs. cross-country) or competition level (national vs. international). This contrasts with studies in other sports, where international-level athletes tend to consume more NS than national [ 13 , 19 , 29 , 34 , 35 ]. The lack of disparity among skiers may reflect a more homogeneous approach to supplementation in winter sports or indicate that factors such as training conditions, altitude exposure, and cold environments equally influence NS consumption across disciplines and levels. The primary motivations for NS consumption were improving sports performance and maintaining health, consistent with findings in other sports with elite athletes [ 35 ]. Although without significant differences, international-level and cross-country skiers were more likely to consume NS for performance enhancement, whereas alpine and international athletes prioritized health-related benefits. This pattern could reflect the different physiological demands of these skiing disciplines, with cross-country skiing requiring greater endurance and metabolic efficiency compared to alpine skiing. Another significant aspect of this study is the purchasing sources of NS. Pharmacies and the internet were the most common purchasing locations, aligning with trends observed in other athlete populations [ 32 ]. The results presented here diverge significantly from those documented for elite Spanish athletes across multiple disciplines, who exhibited a pharmacy purchase rate of approximately 1% for sports supplements [ 34 ]. The preference for pharmacies suggests a cautious approach to NS acquisition, potentially to avoid contamination risks associated with unregulated online markets [ 36 ]. Numerous investigations have documented the internet's widespread use as one of the main avenues for acquiring athletic nutritional aids [ 36 – 37 ]. A body of scholarly work has underscored the perils associated with online supplement procurement, noting that such products may harbor undeclared ingredients, inaccurate concentrations, or extraneous pollutants, thereby jeopardizing athletes' well-being, competitive abilities, and professional standing [ 38 – 39 ]. This pattern raises concerns that a considerable portion of the athletes examined may have faced potential hazards due to the absence of uniform international oversight of nutritional supplements. Dangers such as product adulteration, inadequate guidance on appropriate usage, and the absence of robust scientific validation amplify the probability of inappropriate or excessive supplement intake, or inadvertent doping, particularly within the uncontrolled online marketplace [ 40 ]. The data collected reveal that the skiers surveyed primarily identified physicians and dietitians as their preferred sources of nutritional guidance, a departure from the practice observed in recreational or collegiate athletes. These latter groups often seek counsel from non-credentialed individuals, such as strength and conditioning specialists [ 41 – 42 ], prior to consulting qualified dietitians or medical practitioners. It is imperative to underscore the significance of obtaining advice from reputable sources, given that inaccurate information and inadequate direction can precipitate the use of supplements lacking scientific support or, more concerningly, contribute to inadvertent doping and adverse health outcomes [ 38 , 43 ]. Furthermore, athletes who prioritize physicians or dietitians as their principal sources of nutritional expertise typically demonstrate superior dietary patterns, a more refined understanding of nutrient timing, and a greater propensity to make evidence-based decisions concerning sports supplements [ 43 – 44 ]. Elite skiing competitors face unique nutritional challenges due to the strenuous demands of their sport and the hypoxic conditions encountered at high altitudes, which can impair performance and increase oxidative stress. A narrative review of elite cross-country skiers’ nutritional strategies underscores that optimal energy availability and macronutrient intake are vital for performance and recovery (Heikura et al., 2021). Therefore, NS use in this population can be helpful. Our findings indicate that vitamin C (23.1%), vitamin D (15.4%), and green tea (10.3%) are the most commonly used NS. These findings contrast with the results reported by Kalhor and Eizadi (2023), who found that skiers in Tehran used supplements such as protein powder (52%), amino acids (48%), vitamins (57%), creatine (61%), glutamine (77%), and testosterone (31%), illustrating the variability in supplement use across regions and athlete populations. High-altitude training can elevate reactive oxygen species and oxidative stress, and vitamin and mineral supplements have been shown to mitigate these effects; for example, skiers training at 1800 meters for five days who received vitamin C supplements exhibited a significant reduction in malondialdehyde levels and an increase in superoxide dismutase activity, thereby reducing lipid peroxidation caused by hypoxia [ 45 – 46 ]. These findings support the widespread use of vitamin C among skiers, likely due to its antioxidant capacity as well as its immune-boosting, fatigue-reducing, coordination-improving, and endurance-enhancing effects [ 47 ]. The prominence of vitamin D supplementation is especially relevant given the risk of deficiency in winter sports athletes caused by limited sun exposure [ 8 ], while the moderate use of caffeine supplement suggests an interest in ergogenic aids, even though the relatively low adoption of performance-enhancing supplements. Regarding caffeine supplement, the International Society of Sports Nutrition (ISSN) emphasizes that improves various aspects of exercise performance—including muscle endurance, speed, strength, sprinting, and jumping—and its ability to enhance race performance in cross-country skiers has been well documented [ 48 – 49 ]. Conversely, there are no studies related to green tea and sport performance in skiers; therefore, its use lacks evidence. Overall, according to AIS (2023) classification, the most commonly used supplements belong to Group A (e.g., vitamin D, caffeine, whey protein, zinc, and multivitamin complex), followed by Group C (e.g., green tea, pollen, magnesium, and royal jelly) and finally Group B (e.g., vitamin C and omega-3), reflecting a general preference for products with robust scientific support. The analysis of NS consumption among elite skiers showed no significant differences between alpine and cross-country disciplines or between national and international competitors. While vitamin C, vitamin D, green tea, and omega-3 had similar usage rates across groups, caffeine consumption was higher in cross-country skiers, though not statistically significant. Whey protein and zinc were used only by alpine skiers, whereas magnesium showed a borderline significant trend of higher consumption among cross-country skiers. In any case, the findings show the overall consumption rates of sports foods, medical supplements, and performance supplements were relatively low compared to other elite athletes [ 20 – 21 ], which may be attributed to a lack of awareness about optimal NS use or logistical challenges in accessing these products during training and competitions. For elite athletes, a “food first” nutritional strategy is recommended, reserving supplements solely for achieving specific health and performance objectives, with meticulous recording of supplement dosages and durations, and close monitoring of both beneficial and adverse effects [ 50 ]. Even though most supplements used by these athletes fall under Group A, and although more research is necessary in this sport, elite skiers are not fully capitalizing on other ergogenic aids with proven performance benefits, such as sports foods, β-alanine, sodium bicarbonate, creatine, or nitrate [ 51 – 56 ]. Although NS are widely used among athletes, the current attention given to their use and commercialization is inadequate, largely due to the lack of a regulatory body overseeing their safety, efficacy, and the validation of their claimed benefits [ 57 ]. Standardizing and categorizing NS is essential for proper regulation, and critical areas for research and education include assessing the risks associated with NS use, optimizing their effective application, and enhancing nutrient intake from whole foods to reduce reliance on supplements [ 27 ]. Given their potential influence on the performance and health of elite skiers, it is imperative that professionals advising these athletes possess a thorough understanding of responsible supplement use, with a focus on efficacy, safety, and legality [ 13 ]. Moreover, despite their widespread use, the application of NS remains suboptimal, making it crucial to conduct cost–benefit analyses and individualized nutritional assessments to ensure that supplement consumption does not replace a balanced diet or proper nutrition [ 57 – 58 ]. The indiscriminate use of NS raises significant concerns, highlighting the need for early educational interventions for athletes, coaches, and family members [ 38 ]. Therefore, it is important to plan awareness and educational intervention programs regarding supplement consumption for elite Turkish skiers in the future. Despite these valuable insights, the study has some limitations. The sample size is relatively small, limiting the generalizability of findings to all elite Turkish skiers. Additionally, self-reported data may be subject to recall bias, and the cross-sectional design prevents establishing causal relationships. Future research should explore longitudinal NS consumption trends in skiing and assess the impact of targeted nutritional interventions on performance and recovery. Addressing gaps in knowledge and ensuring that supplementation strategies align with scientific evidence will be crucial in enhancing the overall health and competitive success of elite skiers. Therefore, future research should explore longitudinal trends in NS consumption among skiers, as well as investigate the impact of specific supplements on muscle damage, training adaptation, and recovery in cold and high-altitude environments. Additionally, intervention-based studies examining the effects of tailored supplementation programs on skiers’ performance, endurance, and metabolic efficiency could provide valuable insights to refine nutritional recommendations for winter sports athletes. CONCLUSIONS In conclusion, this study highlights that NS consumption among Turkish elite skiers is lower than in other elite athletes and sports, with only 28.2% using NS and an average consumption rate of 1.2 ± 1.4. The primary sources for purchasing supplements—pharmacies (28.2%)—and the main advisors—physicians (23.1%)—are generally reliable. The most common motivations for NS use were maintaining health (28.2%) and improving sports performance (25.6%), with vitamin C (23.1%), vitamin D (15.4%), and green tea (10.3%) being the most frequently consumed supplements. Moreover, none of these findings were significantly influenced by competition type or level. While the majority of supplements used by the sample are supported by strong scientific evidence, the relatively low consumption of performance-enhancing supplements suggests a need for greater awareness of their potential benefits. Additionally, given the risk of contamination in unregulated supplements and the notable prevalence of online purchases (14.4%), targeted educational interventions for both athletes and coaching staff are strongly recommended. This underscores the importance of ensuring that skiers receive accurate and up-to-date information on NS safety, efficacy, and legality. Declarations Acknowledgements: We express our gratitude to the Turkish Ski Federation and all the participants for their collaboration. Author Contributions: EG performed study design, data analysis, and original draft writing and review. AJSO performed study design, original draft writing, and review. Ö.A., S.T., and B.Y. performed data collection and original draft writing. Lastly, I.K.C. contributes to study design and statistical analysis. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved the final manuscript for publication. Funding: This study did not receive any funding from external sources. Data Availability: Data will be made available on request Conflicts of Interest: The authors declare no conflict of interest. Ethical Approval : This study approved by the Yeditepe University Non-Interventional Clinical Research Ethics Committee (Meeting Date: 13.01.2023; Application Number: 202301Y0338). 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A survey on dietary supplement consumption in amateur and professional rugby players. Foods 10(1):7 Dwyer JT (2018). Dietary supplements: Regulatory challenges and research resources. Nutrients 10(1):41 Seifert JG et al (2012). The effects of a carbohydrate-protein gel supplement on alpine slalom ski per-formance. J Sport Sci Med 11:537–541 Sayan H et al (2000). Yüksek irtifada antrenman yapan kayakçılarda c vitaminin eritrosit süperoksit dismutaz enzim aktivitesi ve lipid peroksidasyonu düzeylerine etkisi. Turkiye Klinikleri J Med Sci 20(1):5-10 Seifert JG (2005). Muscle damage, fluid ingestion, and energy supplementation during recreational Alpine skiing. Int J Sport Nutr Exerc Metab 15:528–536 Ronsen O et al (1999). Supplement use and nutritional habits in Norwegian elite athletes. Scand J Med Sci Sports 9(1): 28–35 Sánchez-Oliver AJ (2013). Suplementación nutricional en la actividad físico-deportiva. análisis de la calidad del suplemento proteico consumido. Ph.D. Thesis, Universidad de Granada, Granada, Spain. Caraballo I et al (2020). Analysis of sports supplements consumption in young Spanish elite dinghy sailors. Nutrients 12(4): 993 Muñoz A et al (2020). Use of sports supplements in competitive handball players: sex and competitive level differences. Nutrients 12(11): 3357 Sánchez-Oliver AJ et al (2024) Cuestionario sobre consumo de suplementos deportivos. manual de uso. Available online: http://hdl.handle.net/10045/144759 Australian Institute of Sport Sports Supplement Framework. [(Accessed on 27 July 2022)]; Available Online: https://www.ais.gov.au/nutrition/supplements Jiménez-Alfageme R et al (2023) Are the consumption patterns of sports supplements similar among Spanish mountain runners? Nutrients 15:262 Jiménez-Alfageme R et al (2023) Do Spanish triathletes consume sports supplements according to scientific evidence? An analysis of the consumption pattern according to sex and level of competition. Nutrients 15: 1330 Baltazar-Martins G et al (2019) Prevalence and patterns of dietary supplement use in elite Spanish athletes. J Int Soc Sports Nutr 16(1): 30 Ventura Comes A et al (2018) Analysis of nutritional supplements consumption by squash players. Nutrients 10:1341 Geyer H et al (2008) Nutritional supplements cross-contaminated and faked with doping substances. J Mass Spectrom 43:892–902 Martinez-Sanz JM et al (2017) Current status of legislation on dietary products for sports people in a European framework. Nutrients 9:1225 Garthe I, Maughan RJ (2018) Athletes and supplements: Prevalence and perspectives. Int J Sport Nutr Exerc Metab 28:126–138 Garthe I, Ramsbottom R (2020) Elite athletes, a rationale for the use of dietary supplements: A practical approach. PharmaNutrition 14:100234 Martinez-Sanz JM et al (2021) Fraud in nutritional supplements for athletes: A narrative review. Nutr Hosp 38:839–847. Burns RD et al (2004) Intercollegiate student athlete use of nutritional supplements and the role of athletic trainers and dietitians in nutrition counseling. J Am Diet Assoc 104: 246–249 Lopez-Samanes A et al (2017) Use of nutritional supplements and ergogenic aids in professional tennis players. Nutr Hosp 34:1463–1468 Martinez-Sanz JM et al (2017) Intended or Unintended Doping? A Review of the Presence of Doping Substances in Dietary Supplements Used in Sports. Nutrients 9:1093 Hull MV et al (2016) Gender differences and access to a sports dietitian influence dietary habits of collegiate athletes. J Int Soc Sports Nutr 13:38. Burtscher M et al (2018) Preparation for Endurance Competitions at Altitude: Physiological, Psychological, Dietary and Coaching Aspects. A Narrative Review. Front Physiol 9:1504 Sayan H et al (2000) Yüksek İrtifada Antrenman Yapan Kayakçılarda C Vitaminin Eritrosit Süperoksit Dismutaz EnzimAktivitesi Ve Lipid Peroksidasyonu Düzeylerine Etkisi. Turkiye Klinikleri J Med Sci 20(1): 5-10 Ghazzawi HA et al (2023). Exploring the Relationship between Micronutrients and Athletic Performance: A Comprehensive Scientific Systematic Review of the Literature in Sports Medicine. Sports 11(6): 109 Guest NS et al (2021). International society of sports nutrition position stand: caffeine and exercise performance. J Int Soc Sports Nutr 18(1):1 Berglund B, Hemmingsson P (1982). Effects of caffeine ingestion on exercise performance at low and high altitudes in cross-country skiers. Int J Sports Med 3(04):234-236 Collins J et al (2021) UEFA expert group statement on nutrition in elite football. Current evidence to inform practical recommendations and guide future research. Br J Sports Med 55:416. Trexler ET et al (2015) International society of sports nutrition position stand: Beta-Alanine. J Int Soc Sports Nutr 12:30 Kreider RB et al (2017) International Society of Sports Nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine. J Int Soc Sports Nutr 14:18 Kerksick CM et al. (2018) ISSN exercise & sports nutrition review update: research & recommendations. J Int Soc Sports Nutr 15(1):38 Coggan AR et al (2021) Effect of dietary nitrate on human muscle power: a systematic review and individual participant data meta-analysis. J Int Soc Sports Nutr 18(1):66 Grgic J et al (2021) International Society of Sports Nutrition position stand: sodium bicarbonate and exercise performance. J Int Soc Sports Nutr 18(1):61 Kerksick CM et al. (2017) International society of sports nutrition position stand: nutrient timing. J Int Soc Sports Nutr 14:33 Mata-Ordoñez F et al (2018) Suplementación en el deporte: Directrices desde la responsabilidad profesional. Mot Rev Cienc Act Fís Deport 51:4–12 Maughan RJ et al (2007) The use of dietary supplements by athletes. J Sports Sci 25 (Suppl. S1): S103–S113 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6251321","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":440780261,"identity":"120a298e-8750-4735-a1d4-5fbdae3e165a","order_by":0,"name":"Elif Günalan","email":"","orcid":"","institution":"Istanbul Health and Technology University","correspondingAuthor":false,"prefix":"","firstName":"Elif","middleName":"","lastName":"Günalan","suffix":""},{"id":440780262,"identity":"f10de356-5cf9-4f9f-9051-253870505d76","order_by":1,"name":"Antonio Jesús Sanchez-Oliver","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYJACZhDBByYrSNHCBibPkKQFRDC2EaFcvv3swc8FFXVybOw8ho8r5x22Z2Bvf4BXi8GZvGTpGWfYjNmYeYwNz247nNjAc8YAvxaGHDNm3jaexDZmtjTJxm2HExgkcgg4rP8NUMs/CZCW9J+Nc4AOk3+O32EMN0C2NBgAtTAfY2xsOMzYIMFAwGE33hhL8xxLAPqF+bBkw7H0xDaeHPxa5PtzDD/z1NTJ8fMfbPzYUGNtz89+nIDDMAAbiepHwSgYBaNgFGABAAodOb+LzdnfAAAAAElFTkSuQmCC","orcid":"","institution":"University of Seville","correspondingAuthor":true,"prefix":"","firstName":"Antonio","middleName":"Jesús","lastName":"Sanchez-Oliver","suffix":""},{"id":440780263,"identity":"47722471-4b8d-4bc4-90db-cbcb534d3069","order_by":2,"name":"Saadet Turhan","email":"","orcid":"","institution":"Istinye University","correspondingAuthor":false,"prefix":"","firstName":"Saadet","middleName":"","lastName":"Turhan","suffix":""},{"id":440780264,"identity":"306206f1-2ba8-4cbf-b83a-ec470e28d634","order_by":3,"name":"Öykü Altınok","email":"","orcid":"","institution":"Fenerbahçe University","correspondingAuthor":false,"prefix":"","firstName":"Öykü","middleName":"","lastName":"Altınok","suffix":""},{"id":440780265,"identity":"d06f8753-c205-4eb3-ba39-2d8ccf633657","order_by":4,"name":"Betül Yıldırım Çavak","email":"","orcid":"","institution":"Istanbul Health and Technology University","correspondingAuthor":false,"prefix":"","firstName":"Betül","middleName":"Yıldırım","lastName":"Çavak","suffix":""},{"id":440780266,"identity":"4dc5ac1a-f73b-4e8e-9702-254fe24c09da","order_by":5,"name":"İrem Kaya Cebioğlu","email":"","orcid":"","institution":"Yeditepe University","correspondingAuthor":false,"prefix":"","firstName":"İrem","middleName":"Kaya","lastName":"Cebioğlu","suffix":""}],"badges":[],"createdAt":"2025-03-18 09:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6251321/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6251321/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81948295,"identity":"f1fb033e-0998-4d62-8f2a-36c538bd3275","added_by":"auto","created_at":"2025-05-05 08:38:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":789245,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6251321/v1/e51624b4-31b0-4d59-891b-7c90f67ab627.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of Nutritional Supplements Use in Turkish Elite Skiers","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSkiing, an intermittent strength-endurance activity, is performed at medium to high intensity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It takes place on ice or snow, in cold conditions (air temperature between \u0026minus;\u0026thinsp;25 and +\u0026thinsp;5\u0026deg;C), and at medium to high altitudes (average 2500 m) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Skiers have unique nutritional needs due to the nature of their sport. For instance, they require increased energy intake to fuel their rigorous activity, and they need to replenish their glycogen stores due to the intense muscle contractions that occur throughout a turn. These repeated stimuli force the glycolytic energy system and thus affect muscle glycogen stores [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite their rigorous training, winter sports athletes face myriad unique nutritional challenges due to the demanding conditions of their sport. These challenges, including increased energy expenditure, accelerated glycogen utilization, fluid loss, and iron conversion, significantly impact their nutritional status and can lead to metabolic, thermoregulatory, and cardiovascular complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCold exposure increases the glycolytic capacity and glycogenolysis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Significant levels of ischemia and hypoxia may occur while skiing [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Ischemia may negatively affect metabolism by increasing glycogen utilization or decreasing glucose uptake by muscle [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Altitude also increases the iron requirements due to its role in oxygen transport and energy metabolism [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFluid balance is a cornerstone of exercise performance and athlete health in winter sports [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Exposure to altitude triggers diuresis, decreases thirst, and improves ventilation in low-humidity environments, posing a risk of dehydration and decreased total body water [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These factors, when combined, can lead to rapid onset of fatigue, impaired performance, and various nutritional complications at low temperatures and high altitudes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEnergy, nutrient, and fluid intake are critical to skiers [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Nutritional deficits can adversely impact the performance and health of athletes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Several previous studies have unfortunately pointed out that skiers' dietary habits are insufficient to meet the needs of the sport [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Studies have demonstrated deficiencies in athletes' fluid intake [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], energy intake [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], carbohydrate consumption [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and vitamin and mineral intake [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Exposure to high altitudes may exacerbate these deficiencies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor skiers, specific supplements can be particularly beneficial. For instance, carbohydrate supplements can help replenish glycogen stores, and iron supplements can address the increased iron requirements due to altitude exposure. Nutritional supplements (NS) are \"food, food component, nutrient, or non-food compound that is purposefully ingested in addition to the habitually consumed diet to achieve a specific health and performance benefit\". NS aim to supplement dietary deficiencies by containing substances with nutritional or specific physiological effects [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. They may be in capsules, tablets, pills, granules, chewable tablets, or gums [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSupplements are essential in improving sports performance and supporting exercise programs [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, the key to their effectiveness lies in using appropriate supplements at the right time. This can increase athletes' sports performance, accelerate recovery, and delay fatigue [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The use of NS by athletes and people participating in sports activities has increased significantly over the past few decades [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It varies between 30% and 95% depending on the sport, gender, age, or level of competition [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In addition, the supplement market is constantly expanding, and the variety of products continues to increase [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Only a tiny portion of the supplements available on the market have demonstrated significant effects on performance despite their widespread use and growing market [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Therefore, selecting the appropriate and safe product based on the specific characteristics of the sport and the athlete's condition has become a crucial issue [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome studies have reported potential beneficial effects of NS consumption on muscle damage, perceptions of effort, training volume, and sports performance in skiers of certain ages and genders across different skiing disciplines [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These findings offer promising potential for NS to enhance skiers' performance significantly. However, limited studies have examined the prevalence of supplement use in skiers [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Therefore, this study aims to investigate NS consumption profile in Turkish elite skiers of different competition fields and levels.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis cross-sectional study examined the NS consumption patterns of Turkish skiers in the Alpine and Cross-country disciplines.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThis study aimed to reach all elite Alpine or Cross-country skiing volunteer athletes affiliated with the T\u0026uuml;rkiye Ski Federation. For this purpose, approval was obtained from the Yeditepe University Non-Interventional Clinical Research Ethics Committee (Meeting Date: 13.01.2023; Application Number: 202301Y0338). Afterward, legal permissions were obtained from the federation for cooperation. The federation shared the contact numbers of the authorities in all provinces and contributed to reaching the athletes. After telephone interviews with provincial ski authorities, data collection form links were sent to the skiers\u0026rsquo; coaches. Participants completed an online NS consumption-related specific questionnaire in Google Forms (Google, Mountain View, CA, USA). The calculation for the sample size was performed using the Sample Size Calculator from the Australian Bureau of Statistics with a confidence level set at 95% (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.abs.gov.au/websitedbs/D3310114.nsf/home/Sample+Size+Calculator\u003c/span\u003e\u003cspan address=\"https://www.abs.gov.au/websitedbs/D3310114.nsf/home/Sample+Size+Calculator\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e Based on information from the Turkish Ski Federation website, the target population comprised 8,900 skiers at both national and international levels (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://tkf.org.tr/\u003c/span\u003e\u003cspan address=\"https://tkf.org.tr/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e Assuming an anticipated proportion of 0.9, the resulting sample consisted of 36 skiers, featuring a confidence interval of 0.09, a standard error of 0.05, and a relative standard error of 5.56. Inclusion criteria included being an elite skier, 18 or older, and competing in Alpine or Cross-country skiing branches. At the end of this process, 39 elite skiers (13 female, 26 male) in the Alpine and Cross-country disciplines participated in the study.\u003c/p\u003e\n\u003ch3\u003eData collection form\u003c/h3\u003e\n\u003cp\u003eA previously validated questionnaire was used for data collection, having undergone thorough content, structure, and applicability reviews [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This questionnaire, assessed for methodological quality in a systematic review and meta-analysis by Knapik et al. (2016), was identified as one of 57 validated instruments out of 164 assessed, demonstrating its suitability for obtaining precise data on sports supplement (SS) use among athletes. The validation process by Knapik et al. (2016) utilized an eight-point scale, evaluating factors such as sampling, sample size, measurement tools, bias, response rate, statistical presentation, and participant sample description [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe questionnaire consisted of three main sections: (a) anthropometric and personal data (age, weight, height, years of federation, weekly training days and hours, number of competitions per year); (b) sports practice, including competition category, experience level, weekly training hours, and number of training sessions; and (c) SS consumption habits. This final section explored various aspects of SS use, including types of supplements used, reasons for consumption (e.g., performance enhancement, health maintenance, aesthetics), sources of information (e.g., dietitian/nutritionist, friends, family, physical trainer, physicians), purchasing locations (e.g., pharmacy, internet, specialized stores), frequency and timing of consumption (before, during, and after training/competition), and perceived effects on health and/or athletic performance. Additionally, questions regarding the use of prohibited substances were included, along with a definition of SSs and an updated supplement list [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The questionnaire has been successfully employed in numerous prior studies to assess athletes' patterns of SS use [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Further details regarding the instrument and its user manual can be found in the user guide developed by Sanchez-Oliver et al. (2024) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNS consumption were rigorously categorized using the AIS classification system, a robust framework backed by substantial scientific evidence. In this system, \u003cem\u003eGroup A\u003c/em\u003e supplements have the most substantial scientific evidence and include three subgroups: \u003cem\u003esports foods\u003c/em\u003e (sports drinks, sports gels, sports confectionary, electrolyte supplements, isolated protein supplements, and mixed macronutrient supplements), \u003cem\u003emedical supplements\u003c/em\u003e (iron, calcium, vitamin D, multivitamin complexes, probiotics, and zinc), and \u003cem\u003eperformance supplements\u003c/em\u003e (caffeine, β-alanine, dietary nitrate/beetroot juice, sodium bicarbonate, creatine monohydrate, and glycerol). \u003cem\u003eGroup B\u003c/em\u003e supplements with newly emerging scientific evidence are fruit-derived polyphenols, vitamin C, N-acetyl cysteine, menthol, quinine, transient receptor potential channel agents, collagen, curcumin, ketone, fish oils, and carnitine. \u003cem\u003eGroup C\u003c/em\u003e supplements have not been scientifically proven to provide any advantage to the athletes, and these are magnesium, branched-chain amino acids (BCAA)/leucine, vitamin E, alpha lipoic acid, phosphate, tyrosine, hydroxymethyl butyrate, and prebiotics. Supplements may shift to different groups based on alterations in scientific evidence [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe statistical analyses of the data were analyzed using Jamovi for \u003cem\u003eMacOS\u003c/em\u003e, \u003cem\u003eversion 2.5.4\u003c/em\u003e. In this study, the dependent variables were the parameters related to the athletes' NS consumption, while the independent variables included the type of competition fields and levels. The distribution's normality was examined by applying the Shapiro-Wilk test. For those quantitative variables that met the criteria for normal distribution, an independent sample t-test was used. For all other pairwise comparisons, the Mann-Whitney U Test was performed. Furthermore, the chi-square and Fisher's exact tests were utilized to assess the qualitative parameters, and the odds ratio (OR) was determined to estimate the difference based on competition fields (\u003cem\u003eAlpine vs. Cross-country\u003c/em\u003e) and levels (\u003cem\u003enational vs. international\u003c/em\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThirty-nine elite skiers participated in the study, with 27 Alpine skiers (69.2%) (9 female, 18 male) and 12 cross-country skiers (4 female, 8 male) (30.8%). Among these athletes, 56.4% compete at the national level, while 43.6% compete at the international level. The average age of participants was 23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.78. The education levels of skiers were BSc degree (43.6%), MSc (12.8%), and high school or below degree (43.6%). The average number of weekly training sessions was 5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7. The average session duration mainly was 31\u0026ndash;60 minutes (28.2%), 61\u0026ndash;90 minutes (28.2%), and 91\u0026ndash;120 minutes (15.4%). According to the competition level and type of the skiers, there were no significant differences in age and weekly training sessions in skiers (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cp\u003eAlthough 74.4% of participants previously had used at least one NS, only 28.2% of all participants use them in the season that is carry on the study. Additionally, 56.4% of participants reported being familiar with NS usage laws. The average number of NS consumptions\u0026rsquo; of skiers was 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4. Analysis of current NS usage showed no significant difference in sports discipline (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.709\u003c/em\u003e) (Alpine 25.9% vs. Cross-country 33.3%; OR\u0026thinsp;=\u0026thinsp;0.70 [0.16\u0026ndash;3.07]) or competition level (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.342\u003c/em\u003e) (national 22.7% vs. international 35.3%; OR\u0026thinsp;=\u0026thinsp;0.54 [0.13\u0026ndash;2.21]). Participants mainly preferred NS on the training day (20.5%) before (12.8%) or after (12.8%) sports practice.\u003c/p\u003e\n\u003cp\u003eRegarding the purpose of NS consumption, to take care of health (28.2%) and to improve sport performance (25.6%) were the most popular, with no statistical significance based on the competition field and levels (\u003cem\u003ep\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/em\u003e). Nevertheless, international and cross-country skiers more often consumed NS to increase sports performance, while international and alpine skiers frequently consumed NS to care for their health. The most common places for skiers to purchase NS were Pharmacies (28.2%) and the Internet (15.4%). Cross-country and national competitive skiers preferred NS from the Internet more, while alpine and international skiers mainly purchased NS from pharmacies. However, there were no statistically significant differences in this issue. The main advisors of the participants in NS consumption were physicians (23.1%) and dietitians (15.4%), but the distribution between the groups is quite close to each other in this regard, and there were no statistically significant differences (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDifferences in parameters related to NS consumption according to sports field and levels.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAlpine\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCross-Country\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNational\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInternational\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePurpose of Use\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-to improve sport performance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.14 [0.70\u0026ndash;14.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.282\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.45 [0.56\u0026ndash;10.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- to take care of health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.446\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.40 [0.07\u0026ndash;2.23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.85 [0.45\u0026ndash;7.58]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe Place of NS Purchase\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-In internet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.06\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.25 [0.96\u0026ndash;40.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.679 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.60 [0.09\u0026ndash;3.74]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-In a pharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.446\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.40 [0.07\u0026ndash;2.23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.158 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.15 [0.74\u0026ndash;13.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNS Consumption Advisors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-Physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.17 [0.24\u0026ndash;5.73]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.465\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.87 [0.42\u0026ndash;8.44]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-Dietitian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.15 [0.18\u0026ndash;7.33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.679\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.60 [0.09\u0026ndash;3.74]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u0026nbsp;\u003cem\u003ea\u003c/em\u003e\u0026nbsp;\u003c/sup\u003e \u003cem\u003eindicates Fisher exact test.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the AIS classification of NS (Group A \u0026ndash; subgroups Sport Foods, Medical Supplements, and Performance Supplements \u0026ndash;; Group B and Group C), there were no statistically significant differences in types (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e and competition levels (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDifferences in type of supplement consumption according to the type of competition.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAIS Classification\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAlpine\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCross-country\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e \u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eGroup A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSports Foods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.655\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical Supplements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.873\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerformance Supplements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.401\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal Group A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.468\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.968\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGroup C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.956\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003csup\u003e\u0026nbsp;\u003cem\u003ea\u003c/em\u003e\u0026nbsp;\u003c/sup\u003e \u003cem\u003ep values were calculated via the Mann-Whitney U test.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cimg 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\"\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003csup\u003e\u0026nbsp;\u003cem\u003ea\u003c/em\u003e\u0026nbsp;\u003c/sup\u003e \u003cem\u003ep values were calculated via the Mann-Whitney U test.\u003c/em\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eThe most popular NS for Turkish skiers were vitamin C (23.1%), vitamin D (15.4%), green tea (10.3%), caffeine (7.7%), omega-3 (7.7%), whey protein (7.7%), zinc (7.7%), multivitamin complex (5.1%), pollen (5.1%), magnesium (5.1%), and royal jelly (5.1%). Since the supplement usage rates of subjects are low, further analyses were performed for the most preferred supplements.\u003c/p\u003e\n\u003cp\u003eThe analysis of NS consumption among elite skiers reveals no statistically significant differences between alpine and cross-country disciplines or between national and international competitors for most supplements. For instance, vitamin C (Group B) was used by 25.9% of Alpine and 16.7% of Cross-Country skiers (p\u0026thinsp;=\u0026thinsp;0.693; OR\u0026thinsp;=\u0026thinsp;0.57 [0.10\u0026ndash;3.27]), with similar usage between national (22.7%) and international (23.5%) competitors (p\u0026thinsp;=\u0026thinsp;1.00; OR\u0026thinsp;=\u0026thinsp;1.05 [0.23\u0026ndash;4.69]). Similarly, vitamin D (Group A) consumption was comparable across groups (14.8% vs. 16.7%; p\u0026thinsp;=\u0026thinsp;1.00), as was the use of green tea (Group C) and omega-3 (Group B). Caffeine (Group A) usage showed a trend towards higher consumption among cross-country skiers (16.7% vs. 3.7% in alpine; p\u0026thinsp;=\u0026thinsp;0.219; OR\u0026thinsp;=\u0026thinsp;5.20 [0.42\u0026ndash;63.9]), although this did not reach statistical significance. Notably, supplements such as whey protein and zinc (both Group A) were reported by 11.1% of alpine skiers but by none of the cross-country skiers, yet the differences were not significant (p\u0026thinsp;=\u0026thinsp;0.539). An exception was magnesium (Group C), where 0% of alpine and 16.7% of cross-country skiers reported usage, showing a borderline significance (p\u0026thinsp;=\u0026thinsp;0.089; OR\u0026thinsp;=\u0026thinsp;13.1 [0.58\u0026ndash;296]), suggesting a possible higher reliance on magnesium among Cross-Country athletes (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDifferences in the top ten supplement consumption among skiers by competition fields and levels.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eType of Supplement\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAlpine\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCross-Country\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNational\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInternational\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVitamin C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.693\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.57 [0.10\u0026ndash;3.27]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.05 [0.23\u0026ndash;4.69]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVitamin D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15 [0.18\u0026ndash;7.33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.36 [0.24\u0026ndash;7.75]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGreen Tea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72 [0.07\u0026ndash;7.80]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.618\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.40 [0.04\u0026ndash;4.19]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCaffeine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.20 [0.42\u0026ndash;63.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.570\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.80 [0.23\u0026ndash;33.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOmega-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.14 [0.09\u0026ndash;13.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63 [0.05\u0026ndash;7.53]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhey Protein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.539\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.28 [0.01\u0026ndash;5.86]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.570\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.80 [0.23\u0026ndash;33.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZinc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.539\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.28 [0.01\u0026ndash;5.86]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63 [0.05\u0026ndash;7.53]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePollen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.36 [0.14\u0026ndash;41.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.31 [0.08\u0026ndash;22.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMagnesium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.1 [0.58\u0026ndash;296]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.31 [0.08\u0026ndash;22.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultivitamin Complex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.36 [0.13\u0026ndash;41.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.31 [0.08\u0026ndash;22.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ea indicates Fisher exact test.\u003c/em\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study provides novel insights into the consumption patterns of nutritional supplements (NS) among elite Turkish skiers, specifically in the alpine and cross-country disciplines. The findings reveal that while the majority of participants (74.4%) reported previous NS use, only 28.2% were currently using them during the study period. This prevalence is lower than that observed in endurance athletes such as triathletes and mountain runners, where NS consumption often exceeds 90% [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Moreover, there weren\u0026acute;t differences by level or field, in contrast to a study of international alpine and cross-skiers in Norway, where Ronsen et al. (1999) found that 95% of cross-country skiers used more supplements than 70% of alpine skiers [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These findings differ significantly from other studies with elite athletes, as we observed a very low consumption of NS and no difference in consumption prevalence between national and international athletes [\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. These differences may be attributed to the intermittent nature of skiing and the potential underestimation of nutritional needs in this sport.\u003c/p\u003e \u003cp\u003eA key finding is that no significant differences were observed in NS consumption based on competition type (alpine vs. cross-country) or competition level (national vs. international). This contrasts with studies in other sports, where international-level athletes tend to consume more NS than national [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The lack of disparity among skiers may reflect a more homogeneous approach to supplementation in winter sports or indicate that factors such as training conditions, altitude exposure, and cold environments equally influence NS consumption across disciplines and levels.\u003c/p\u003e \u003cp\u003eThe primary motivations for NS consumption were improving sports performance and maintaining health, consistent with findings in other sports with elite athletes [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Although without significant differences, international-level and cross-country skiers were more likely to consume NS for performance enhancement, whereas alpine and international athletes prioritized health-related benefits. This pattern could reflect the different physiological demands of these skiing disciplines, with cross-country skiing requiring greater endurance and metabolic efficiency compared to alpine skiing.\u003c/p\u003e \u003cp\u003eAnother significant aspect of this study is the purchasing sources of NS. Pharmacies and the internet were the most common purchasing locations, aligning with trends observed in other athlete populations [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The results presented here diverge significantly from those documented for elite Spanish athletes across multiple disciplines, who exhibited a pharmacy purchase rate of approximately 1% for sports supplements [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The preference for pharmacies suggests a cautious approach to NS acquisition, potentially to avoid contamination risks associated with unregulated online markets [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Numerous investigations have documented the internet's widespread use as one of the main avenues for acquiring athletic nutritional aids [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. A body of scholarly work has underscored the perils associated with online supplement procurement, noting that such products may harbor undeclared ingredients, inaccurate concentrations, or extraneous pollutants, thereby jeopardizing athletes' well-being, competitive abilities, and professional standing [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This pattern raises concerns that a considerable portion of the athletes examined may have faced potential hazards due to the absence of uniform international oversight of nutritional supplements. Dangers such as product adulteration, inadequate guidance on appropriate usage, and the absence of robust scientific validation amplify the probability of inappropriate or excessive supplement intake, or inadvertent doping, particularly within the uncontrolled online marketplace [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe data collected reveal that the skiers surveyed primarily identified physicians and dietitians as their preferred sources of nutritional guidance, a departure from the practice observed in recreational or collegiate athletes. These latter groups often seek counsel from non-credentialed individuals, such as strength and conditioning specialists [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], prior to consulting qualified dietitians or medical practitioners. It is imperative to underscore the significance of obtaining advice from reputable sources, given that inaccurate information and inadequate direction can precipitate the use of supplements lacking scientific support or, more concerningly, contribute to inadvertent doping and adverse health outcomes [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Furthermore, athletes who prioritize physicians or dietitians as their principal sources of nutritional expertise typically demonstrate superior dietary patterns, a more refined understanding of nutrient timing, and a greater propensity to make evidence-based decisions concerning sports supplements [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eElite skiing competitors face unique nutritional challenges due to the strenuous demands of their sport and the hypoxic conditions encountered at high altitudes, which can impair performance and increase oxidative stress. A narrative review of elite cross-country skiers\u0026rsquo; nutritional strategies underscores that optimal energy availability and macronutrient intake are vital for performance and recovery (Heikura et al., 2021). Therefore, NS use in this population can be helpful. Our findings indicate that vitamin C (23.1%), vitamin D (15.4%), and green tea (10.3%) are the most commonly used NS. These findings contrast with the results reported by Kalhor and Eizadi (2023), who found that skiers in Tehran used supplements such as protein powder (52%), amino acids (48%), vitamins (57%), creatine (61%), glutamine (77%), and testosterone (31%), illustrating the variability in supplement use across regions and athlete populations.\u003c/p\u003e \u003cp\u003eHigh-altitude training can elevate reactive oxygen species and oxidative stress, and vitamin and mineral supplements have been shown to mitigate these effects; for example, skiers training at 1800 meters for five days who received vitamin C supplements exhibited a significant reduction in malondialdehyde levels and an increase in superoxide dismutase activity, thereby reducing lipid peroxidation caused by hypoxia [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. These findings support the widespread use of vitamin C among skiers, likely due to its antioxidant capacity as well as its immune-boosting, fatigue-reducing, coordination-improving, and endurance-enhancing effects [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The prominence of vitamin D supplementation is especially relevant given the risk of deficiency in winter sports athletes caused by limited sun exposure [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], while the moderate use of caffeine supplement suggests an interest in ergogenic aids, even though the relatively low adoption of performance-enhancing supplements. Regarding caffeine supplement, the International Society of Sports Nutrition (ISSN) emphasizes that improves various aspects of exercise performance\u0026mdash;including muscle endurance, speed, strength, sprinting, and jumping\u0026mdash;and its ability to enhance race performance in cross-country skiers has been well documented [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Conversely, there are no studies related to green tea and sport performance in skiers; therefore, its use lacks evidence.\u003c/p\u003e \u003cp\u003eOverall, according to AIS (2023) classification, the most commonly used supplements belong to Group A (e.g., vitamin D, caffeine, whey protein, zinc, and multivitamin complex), followed by Group C (e.g., green tea, pollen, magnesium, and royal jelly) and finally Group B (e.g., vitamin C and omega-3), reflecting a general preference for products with robust scientific support. The analysis of NS consumption among elite skiers showed no significant differences between alpine and cross-country disciplines or between national and international competitors. While vitamin C, vitamin D, green tea, and omega-3 had similar usage rates across groups, caffeine consumption was higher in cross-country skiers, though not statistically significant. Whey protein and zinc were used only by alpine skiers, whereas magnesium showed a borderline significant trend of higher consumption among cross-country skiers. In any case, the findings show the overall consumption rates of sports foods, medical supplements, and performance supplements were relatively low compared to other elite athletes [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], which may be attributed to a lack of awareness about optimal NS use or logistical challenges in accessing these products during training and competitions.\u003c/p\u003e \u003cp\u003eFor elite athletes, a \u0026ldquo;food first\u0026rdquo; nutritional strategy is recommended, reserving supplements solely for achieving specific health and performance objectives, with meticulous recording of supplement dosages and durations, and close monitoring of both beneficial and adverse effects [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Even though most supplements used by these athletes fall under Group A, and although more research is necessary in this sport, elite skiers are not fully capitalizing on other ergogenic aids with proven performance benefits, such as sports foods, β-alanine, sodium bicarbonate, creatine, or nitrate [\u003cspan additionalcitationids=\"CR52 CR53 CR54 CR55\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough NS are widely used among athletes, the current attention given to their use and commercialization is inadequate, largely due to the lack of a regulatory body overseeing their safety, efficacy, and the validation of their claimed benefits [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Standardizing and categorizing NS is essential for proper regulation, and critical areas for research and education include assessing the risks associated with NS use, optimizing their effective application, and enhancing nutrient intake from whole foods to reduce reliance on supplements [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Given their potential influence on the performance and health of elite skiers, it is imperative that professionals advising these athletes possess a thorough understanding of responsible supplement use, with a focus on efficacy, safety, and legality [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Moreover, despite their widespread use, the application of NS remains suboptimal, making it crucial to conduct cost\u0026ndash;benefit analyses and individualized nutritional assessments to ensure that supplement consumption does not replace a balanced diet or proper nutrition [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. The indiscriminate use of NS raises significant concerns, highlighting the need for early educational interventions for athletes, coaches, and family members [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Therefore, it is important to plan awareness and educational intervention programs regarding supplement consumption for elite Turkish skiers in the future.\u003c/p\u003e \u003cp\u003eDespite these valuable insights, the study has some limitations. The sample size is relatively small, limiting the generalizability of findings to all elite Turkish skiers. Additionally, self-reported data may be subject to recall bias, and the cross-sectional design prevents establishing causal relationships. Future research should explore longitudinal NS consumption trends in skiing and assess the impact of targeted nutritional interventions on performance and recovery.\u003c/p\u003e \u003cp\u003eAddressing gaps in knowledge and ensuring that supplementation strategies align with scientific evidence will be crucial in enhancing the overall health and competitive success of elite skiers. Therefore, future research should explore longitudinal trends in NS consumption among skiers, as well as investigate the impact of specific supplements on muscle damage, training adaptation, and recovery in cold and high-altitude environments. Additionally, intervention-based studies examining the effects of tailored supplementation programs on skiers\u0026rsquo; performance, endurance, and metabolic efficiency could provide valuable insights to refine nutritional recommendations for winter sports athletes.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eIn conclusion, this study highlights that NS consumption among Turkish elite skiers is lower than in other elite athletes and sports, with only 28.2% using NS and an average consumption rate of 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4. The primary sources for purchasing supplements\u0026mdash;pharmacies (28.2%)\u0026mdash;and the main advisors\u0026mdash;physicians (23.1%)\u0026mdash;are generally reliable. The most common motivations for NS use were maintaining health (28.2%) and improving sports performance (25.6%), with vitamin C (23.1%), vitamin D (15.4%), and green tea (10.3%) being the most frequently consumed supplements. Moreover, none of these findings were significantly influenced by competition type or level.\u003c/p\u003e \u003cp\u003eWhile the majority of supplements used by the sample are supported by strong scientific evidence, the relatively low consumption of performance-enhancing supplements suggests a need for greater awareness of their potential benefits. Additionally, given the risk of contamination in unregulated supplements and the notable prevalence of online purchases (14.4%), targeted educational interventions for both athletes and coaching staff are strongly recommended. This underscores the importance of ensuring that skiers receive accurate and up-to-date information on NS safety, efficacy, and legality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe express our gratitude to the Turkish Ski Federation and all the participants for their collaboration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eEG performed study design, data analysis, and original draft writing and review. AJSO performed study design, original draft writing, and review. \u0026Ouml;.A., S.T., and B.Y. performed data collection and original draft writing. \u0026nbsp;Lastly, I.K.C. contributes to study design and statistical analysis. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved the final manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study did not receive any funding from external sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e Data will be made available on request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e: This study approved by\u0026nbsp;the Yeditepe University Non-Interventional Clinical Research Ethics Committee (Meeting Date: 13.01.2023; Application Number: 202301Y0338).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e: Informed consent obtained from all participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eConde-Pip\u0026oacute; J et al (2022). 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[(Accessed on 27 July 2022)]; Available Online: https://www.ais.gov.au/nutrition/supplements\u003c/li\u003e\n\u003cli\u003eJim\u0026eacute;nez-Alfageme R et al (2023) Are the consumption patterns of sports supplements similar among Spanish mountain runners? Nutrients 15:262\u003c/li\u003e\n\u003cli\u003eJim\u0026eacute;nez-Alfageme R et al (2023) Do Spanish triathletes consume sports supplements according to scientific evidence? An analysis of the consumption pattern according to sex and level of competition. Nutrients 15: 1330\u003c/li\u003e\n\u003cli\u003eBaltazar-Martins G et al (2019) Prevalence and patterns of dietary supplement use in elite Spanish athletes. J Int Soc Sports Nutr 16(1): 30\u003c/li\u003e\n\u003cli\u003eVentura Comes A et al (2018) Analysis of nutritional supplements consumption by squash players. Nutrients 10:1341\u003c/li\u003e\n\u003cli\u003eGeyer H et al (2008) Nutritional supplements cross-contaminated and faked with doping substances. 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J Int Soc Sports Nutr 18(1):66\u003c/li\u003e\n\u003cli\u003eGrgic J et al (2021) International Society of Sports Nutrition position stand: sodium bicarbonate and exercise performance. J Int Soc Sports Nutr 18(1):61 \u003c/li\u003e\n\u003cli\u003eKerksick CM et al. (2017) International society of sports nutrition position stand: nutrient timing. J Int Soc Sports Nutr 14:33 \u003c/li\u003e\n\u003cli\u003eMata-Ordo\u0026ntilde;ez F et al (2018) Suplementaci\u0026oacute;n en el deporte: Directrices desde la responsabilidad profesional. Mot Rev Cienc Act F\u0026iacute;s Deport 51:4\u0026ndash;12\u003c/li\u003e\n\u003cli\u003eMaughan RJ et al (2007) The use of dietary supplements by athletes. J Sports Sci 25 (Suppl. S1): S103\u0026ndash;S113\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Athletes, Dietary Supplements, Winter Sports, Sport Supplements","lastPublishedDoi":"10.21203/rs.3.rs-6251321/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6251321/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWinter sports athletes are challenged with increased energy expenditure, glycogen utilization, and fluid loss due to cold environmental conditions. Nutritional supplements (NS) may provide improved health or performance, more effective training, and a direct performance advantage for winter sports athletes like skiers.\u003c/p\u003e\u003ch2\u003eAims\u003c/h2\u003e \u003cp\u003eThis study evaluates NS consumption in Turkish elite skiers of different competition fields (Alpine skiing vs. Cross-country skiing) and levels (national vs. international) according to Australian Sports Institute (AIS) criteria.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThirty-nine Turkish elite skiers (Alpine, n\u0026thinsp;=\u0026thinsp;27 and Cross-country, n\u0026thinsp;=\u0026thinsp;12) completed an NS consumption-related specific questionnaire, which included parts of personal characteristics, sports/ training, and consumption patterns of NS.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAlthough 74.4% had previously used NS, only 28.2% consumed them during the study season. No significant differences were found in NS use between skiing disciplines (p\u0026thinsp;=\u0026thinsp;0.709) or competition levels (p\u0026thinsp;=\u0026thinsp;0.342). The most common reasons for NS use were health maintenance (28.2%) and performance enhancement (25.6%). Popular NS included vitamin C (23.1%), vitamin D (15.4%), and green tea (10.3%), with pharmacies (28.2%) and the Internet (15.4%) being the main purchasing sources. Physicians (23.1%) and dietitians (15.4%) were the primary advisors, although no significant differences were observed between groups regarding supplement use.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlights that NS consumption among Turkish elite skiers is lower than in other endurance sports and is not significantly influenced by competition type or level. The findings emphasize the need for enhanced education on evidence-based supplementation strategies tailored to the unique demands of winter sports.\u003c/p\u003e","manuscriptTitle":"Analysis of Nutritional Supplements Use in Turkish Elite Skiers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-16 10:23:32","doi":"10.21203/rs.3.rs-6251321/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0eed0229-9b24-483c-a300-652df5ee1d60","owner":[],"postedDate":"April 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T08:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-16 10:23:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6251321","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6251321","identity":"rs-6251321","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}